Information Collection

Medical Examination for Immigrant or Refugee Applicant

IC 38745 under ICR 201407-1405-004 · OMB 1405-0113.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0113 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-3025 Medical Examination for Immigrant or Refugee Applicant	Form and Instruction
DS-3025 Vaccination Documentation Worksheet DS 3025 Paper Form (7-2014).docx	Form and Instruction
DS-3026 Medical History and Physical Examination Worksheet DS 3026 Paper Form (7-2014).docx	Form and Instruction
DS-2053 Medical Examination for Immigrant or Refugee Applicant DS-2053 Paper Form (7-2014).docx	Form and Instruction
DS-2054 Medical Examination for Immigrant or Refugee Applicant DS-2054 Paper Form (7-2014).docx	Form and Instruction
DS-3024 Chest X-Ray and Classification Worksheet DS-3024 Paper Form (1991 x-ray) (7-2014).docx	Form and Instruction
DS-3030 Tuberculosis Worksheet DS-3030 Paper Form (7-2014).docx	Form and Instruction

IC Title:

Medical Examination for Immigrant or Refugee Applicant

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	DS-3025	Vaccination Documentation Worksheet	DS 3025 Paper Form (7-2014).docx	No	Fillable Printable
Form and Instruction	DS-3026	Medical History and Physical Examination Worksheet	DS 3026 Paper Form (7-2014).docx	No	Fillable Printable
Form and Instruction	DS-2053	Medical Examination for Immigrant or Refugee Applicant	DS-2053 Paper Form (7-2014).docx	No	Fillable Printable
Form and Instruction	DS-2054	Medical Examination for Immigrant or Refugee Applicant	DS-2054 Paper Form (7-2014).docx	No	Fillable Printable
Form and Instruction	DS-3024	Chest X-Ray and Classification Worksheet	DS-3024 Paper Form (1991 x-ray) (7-2014).docx	No	Fillable Printable
Form and Instruction	DS-3030	Tuberculosis Worksheet	DS-3030 Paper Form (7-2014).docx	No	Fillable Printable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title: SORN Visa Records, State-39

FR Citation: 60 FR 148

Number of Respondents: 660,000

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	660,000	30,000	630,000
Annual IC Time Burden (Hours)	660,000	30,000	630,000
Annual IC Cost Burden (Dollars)	290,250,000	6,750,000	283,500,000

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.